Background Check Consent PB

Patient's Name *

First

Last

For office purposes.

Relationship to Patient *

Full Name: Last, First, MI *

Maiden / Other Names Used *

Enter N/A if this field does not apply to you.

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security # *

Social Security Card Upload *

Click or drag a file to this area to upload.

Please take a photo and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.

Date of Birth *

Please enter in MM/DD/YEAR format (ex.: 07/16/1972)

Drivers License / State ID # *

State Issued *

Photo ID Upload *

Click or drag a file to this area to upload.

Please take a photo of your drivers license (preferred) or some photo ID and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.

Phone *

E-mail

Gender *

Male
Female

Race *

By signing this form, you are swearing that the information you have provided is true and correct to the best of your knowledge; you are giving permission for a security check to be run, including a criminal background; you are consenting to RMHC sharing acquired information with relevant medical facility personnel; and you are agreeing to conform to all policies and regulations as stated in the Guest Rules.

Signature

Dated: *

Please enter date